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Thomas Stark
Medical History The patient suffers from spinal muscular atrophy, an incurable genetic condition that keeps him confined to a wheelchair. He has severe ascending muscle weakness, 28% curvature of the spine, causing reduced lung capacity and reduced bone minimal density. He was constantly accompanied by a helper dog. Case History The patient was brought into Princeton-Plainsboro Teaching Hospital's emergency room when he lost consciousness, the result of a sudden drop in blood pressure that usually would have resulted in fainting then regaining consciousness, but due to his upright position in the wheelchair resulted in persistent unconsciousness. Dr. Kutner suggested running numerous tests. He received assistance from Dr. Brennan, Dr. Cole, Dr. Taub and Dr. Dobson. Dr. Hadley believed that the patient had strongyloides as he had a history of recent travel to Thailand, he would have been lying in the sand where the worm was present, and his symptoms fit that diagnosis. She gave the patient ivermectin tablets. Dr. Kutner and Dr. Brennan arrived soon after to take samples, including taking the patient to the toilet to collect a stool sample. However, they were unable to obtain a stool sample. The hair and blood tests were negative. Dr. Volakis tried xenodiagnosis, having bugs bite the patient and testing the bug feces. However, the patient started choking during the procedure. Dr. Taub intubated the patient. An x-ray showed patchy infiltrates in the lungs. The patient improved on oxygen and chest percussion. It was clear that the patient's airway was unable to distinguish between air and solids and was directing air into the stomach instead of the lungs. Dr. Brennan believed that the fact the symptom was unusual pointed to a disease from Thailand. However. Dr. Hadley pointed out that the patient has a history of difficulty swallowing and the symptom may be related to his spinal muscular atrophy. She still believed it was strongyloides, but Dr. House pointed out that the patient had not improved despite treatment. One of the twins suggested putting the patient on a tilt table to stress his system and Dr. House agreed. Dr. Volakis suggested that they try to find a link between the fainting and difficulty swallowing. Dr. Taub stated they need to determine whether this was the result of dysphasia or achalasia. Dr. Dobson suggested a paraganglioma could be responsible - a tumor in his neck pressing against a nerve. The patient did well on the stress test to 60 degrees with no blood pressure change, nausea or EKG abnormalities. However, Dr. Volakis came into the room and turned up the tilt table to 95 degrees, but the results remained normal. However, Dr. Volakis took a CT scan of the patient's esophagus and found it was straightening, the result of scleraderma. However, Dr. House believed the CT scan merely showed the esophagus was weak, not straight. That would be explained by the spinal muscular atrophy, and strongyloides would still explain the other symptoms. Dr. Volakis persisted and convinced Dr. Chase to run a test for anti-centrum A antibodies. However, when Dr. Volakis drew the blood for the test, it was green. This indicated that the patient's kidneys were not working as the color was from the contrast material used for the CT scan. This appeared to rule out strongyloides. Dr. Hadley thought it might be a gram-negative bacteria from his catheter that made its way to his kidneys and worsened his spinal muscular atrophy. Dr. House ordered intravenous ampigen. Dr. Volakis pointed that it could still be scleraderma. Dr. House ordered a skin biopsy and a lymph node biopsy. The patient developed pneumonia and the antibiotics did not appear to be having an effect. The skin biopsy was normal, but the lymph node biopsy showed black flecks. Although Dr. Brennan thought these were the result of necrosis, Dr. House believed they might be a sign of cancer. Dr. House planned to remove the patient's eye as any debris found in the cervical lymph node must have come from there. However, Dr. Cuddy objected to the plan. She wanted Dr. House to perform another biopsy, but Dr. House pointed out by the time they got the biopsy results back, the patient would most likely be overcome by the pneumonia. Dr. Cuddy finally agreed to the procedure. Dr. Wilson explained to the patient that he most likely had melanoma of the pigment cells in his eye that had spread to his kidney and lungs. However, if this diagnosis was right, the patient would only have a few months to live in any case. As a result, the patient refused to undergo the procedure. Dr. Hadley and Dr. Volakis started to drain the patient's lungs to make him more comfortable. However, they noticed the fluid was clear, where if there was cancer, there should be blood in the fluid. As Dr. House was incapacitated, Dr. Wilson was assigned as attending. Dr. Brennan believed it might be eosinophilic pneumonia. The patient was started on cyclophosphamide. However, his condition continued to deteriorate. He eventually stopped breathing and died. Dr. Hadley called time of death. Dr. House came to the patient's room. It was soon discovered the patient's assistant dog had died as well. Dr. House asked Dr. Hadley if she had made sure the patient had swallowed the ivermectin. Dr. House asked if the dog shared the MDR1 gene with border collies as ivermectin is fatal to those breeds. He soon found the empty medicine cup with the dog's teeth marks on it. He realized the patient did not receive the ivermectin. He admonished Dr. Hadley for failing to admit she had not seen the patient take the pills. The autopsy confirmed that the patient had strongyloides, which had infiltrated his lungs and caused his symptoms. 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